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Hyperthermia NCP
Hyperthermia NCP
Hyperthermia NCP
DIAGNOSIS
RATIONALE
INTERVENTION
RATIONALE
EVALUATION
SUBJECTIVE: May lagnat ako ngayon eh as verbalized by the patient OBJECTIVE: Temp: 38.4 Skin is warm to touch Dry Lips Loss of appetite
Hyperthermia related to stimulation of the thermoregulatory center in the hypothalamus by endogenous pyrogens that are released in an inflammatory process as evidenced by the increase in body temp than normal range
Pyrogens are exogenous or endogenous substances that produce fever. Exogenous pyrogens are derived from outside the body and include such substances as bacterial products, bacterial toxins, or whole microorganisms. Exogenous pyrogens induce host cells to produce feverproducing mediators called endogenous pyrogens
Temperature is ultimately regulated in the hypothalamus. A trigger of the fever, called a pyrogen, causes a release of prostaglandin E2(PGE2). PGE2 then in turn acts on the
After 3 hours of nursing intervention the client will -Reach a temperature of 37.5 or lower
-To obtain an accurate core temperature -Antipyretics act on hypothalamus to regulate temperature
After of nursing intervention client was able to: - Reach a temperature of 37.4
-May help reduce fever .note. use of ice water/ alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to the skin
-Use a hypeothermia blanket if patients temperature rises above 103F. Monitor vital signs every 15minutes for 1 hour and as indicated.
-Monitor heart rate and rhythm, blood pressure, respiratory rate, LOC and level of